Médecine & Droit

Le contentieux de la régularité externe des décisions rendues par les juridictions ordinales des médecins Publication date: Available online 22 December 2020 Source: Médecine & Droit Author(s): Nadia Miloudia

Fallait-il sacrifier le secret professionnel sur l'autel de la santé publique ? Publication date: Available online 7 December 2020 Source: Médecine & Droit Author(s): Bruno Py

Non, le COVID ne mérite pas les justes combats de l'époque du Sida pour le respect du secret médical Publication date: Available online 5 December 2020 Source: Médecine & Droit Author(s): Philippe Biclet

COVID-19: quel rôle pour les comités d'éthique? Publication date: Available online 28 November 2020 Source: Médecine & Droit Author(s): Henri-Corto Stoeklé, Achille Ivasilevitch, Elisabeth Hulier-Ammar, Dominique Reynaert, Christian Hervé

La Direction des Affaires Juridiques et des Droits des Patients de l'APHP et la première vague de la pandémie Covid-19 Publication date: Available online 23 November 2020 Source: Médecine & Droit Author(s): Jacques Belghiti, Marie Pierre Dilly-Rushenas, Sandra Fournier, Magali Richard Piauger, Soisic Iroz, Daniel Vittecoq, Charline Nicolas, Emmanuel Martinod

Corrigendum à « Les grands magasins de la médecine de Milton Friedman » [Med. Droit (Paris). (2020)]. doi:10.1016/j.meddro.2020.07.002 Publication date: Available online 19 November 2020 Source: Médecine & Droit Author(s): Mathieu Ginier-Gillet

Erratum à « L'expertise médicale au temps des pandémies : l'exemple des cancers » [Med. Droit 2020 (2020) 92–95] Publication date: Available online 18 November 2020 Source: Médecine & Droit Author(s): Rémy J. Salmon, Catherine Buffet, Christine Estève

Editorial Board Publication date: October 2020 Source: Médecine & Droit, Volume 2020, Issue 164 Author(s):

L'ADN, la reine des preuves imparfaites Publication date: October 2020 Source: Médecine & Droit, Volume 2020, Issue 164 Author(s): Catherine Ménabé

Le harcèlement : évolution du droit français et problématiques de l'évaluation des victimes Publication date: October 2020 Source: Médecine & Droit, Volume 2020, Issue 164 Author(s): François Van Maris, Gaëtan Prissette, Cécile Manaouil

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Tropical Medicine

Current status and future prospects of bacilli-based vector control Joleen Savianne Almeida, Ajeet Kumar Mohanty, Savita Kerkar, Sugeerappa Laxmanappa Hoti, Ashwani Kumar Asian Pacific Journal of Tropical Medicine 2020 13(12):525-534 Mosquito-borne diseases such as malaria, filariasis, dengue, chikungunya, Japanese encephalitis, yellow fever and Zika contribute significantly to health problems of developing as well as developed nations. Vector control is central to control of vector borne diseases. In the last four-five decades, biological control methods have been inducted in the integrated vector management strategy, advocated nationally as well as globally by the World Health Organization. Currently, biological control of vectors is globally acknowledged as the best available strategy in the wake of growing concerns about vector resistance as well as adverse effects of insecticides on the environment and non-target fauna co-inhabiting the same ecological niches as vectors. In India and elsewhere, efforts are ongoing to screen newer isolates to bring forth new biolarvicidal products of public health importance. In this review, by carrying out extensive literature survey, we discuss advances thus far and the prospects of bacilli-based control of vectors and vector borne diseases.

Patterns of hepatitis B virus exposure and associated predictors in Vietnam: A crosssectional study Minh C Duong, Phuc V.D. Le, Oanh N.K. Pham, Hien D.T. Pham, Toan B Nguyen, Hai T Phan Asian Pacific Journal of Tropical Medicine 2020 13(12):535-541 Objective: To examine the magnitude of isolated anti-HBc and other HBV serological patterns and associated predictors among adults seeking general health check-up at a large health center in Vietnam. Methods: All 564 outpatients seeking general health checkup between January 2016 and December 2016 were asked to undertake HBV surface antigen, surface antibody, IgG and IgM core antibody (anti-HBc total), platelet counts, and liver function testing. An administered questionnaire was used to collect information regarding demography, in-house sources of infection, lifestyle, health condition and treatment, and HBV vaccination. Results: Male gender (P=0.043), age (P=0.000), living in urban areas (P=0.040), HBV vaccination status (P=0.033), and ALT (P=0.040) were associated with isolated anti-HBc. HBV infection was associated with HBV vaccination status (P=0.001), ALT levels (P=0.010), AST levels (P=0.020), and platelet counts (P=0.007). Past/resolved HBV infection was associated with AST levels (P=0.005), ALT levels (P=0.014), and age (P=0.000). Conclusions: Isolated anti-HBc is quite prevalent. Predictors of isolated anti-HBc include male gender, living in rural areas, and HBV non-vaccination. The prevalence of isolated anti-HBc also increases with age. To timely detect occult HBV infection and prevent transmission, anti-HBc testing should be included in the health check-up for high risk individuals and screening program where HBV nucleic acid test is not available. To prevent transmission, clinicians need to pay more attention on those who are at risk of having isolated anti-HBc and closely follow-up patients with isolated anti-HBc and educate them about the prevention of HBV infection.

Morphological and molecular characterization of Acanthamoeba isolated from contact lens paraphernalia in Malaysia: Highlighting the pathogenic potential of T4 genotype Rosnani Hanim Mohd Hussain, Nur Syahirah Mohamad Isa, Khairul Ameera Kamaruddin, Mohamed Kamel Abdul Ghani, Naveed Ahmed Khan, Ruqaiyyah Siddiqui, Tengku Shahrul Anuar Asian Pacific Journal of Tropical Medicine 2020 13(12):542-549 Objective: To determine the morphological and molecular characterization of Acanthamoeba isolates from contact lens paraphernalia in Malaysia and to investigate their pathogenic potential based on the physiological tolerance. Methods: One hundred and eighty contact lens wearers donated their contact lens, lens storage cases and lens solutions between 2018 and 2019. The samples were inoculated onto 1.5% non-nutrient agar plates for 14 d. Polymerase chain reaction (PCR) was performed and the amplified PCR products were sequenced and compared with the published sequences in GenBank. The pathogenic potential of positive isolates was further tested using temperature-tolerance and osmo-tolerance assays. Acanthamoeba species were categorized into three distinct morphological groups established by Pussard and Pons. Results: Acanthamoeba was successfully isolated from 14 (7.8%) culture-positive samples in which 11 belong to morphological group II and 3 belong to morphological group III, respectively. The sequencing of 18S ribosomal RNA gene led to the identification of the T4 genotype in all the isolated strains. In vitro assays revealed that 9 (64.3%) Acanthamoeba isolates were able to grow at 42 °C and 1 M mannitol and were thus considered to be highly pathogenic. Conclusions: To the best of our knowledge, this is the first report identifying the Acanthamoeba genotype and their pathogenic potential among contact lens wearers in Malaysia. The potentially pathogenic T4 genotype isolated in this study is the most predominant genotype responsible for human ocular infection worldwide. Hence, increasing attention should be aimed at the prevention of contamination by Acanthamoeba and the disinfection of contact lens paraphernalia.

Multiplex real-time PCR revealed very high prevalence of soil-transmitted helminth infections among aborigines in Peninsular Malaysia Nurulhasanah Othman, Noorizan Miswan, Weng-kin Wong, Boon-huat Lim, Rahmah Noordin Asian Pacific Journal of Tropical Medicine 2020 13(12):550-556 Objective: To determine the true prevalence of soil-transmitted helminth infections in the Malaysian aborigines using real-time PCR. Methods: A total of 122 aborigines from seven tribes were recruited from settlements and nearby hospitals which served the communities, located in four states in Peninsular Malaysia. The stool samples were examined for the presence of soil-transmitted helminth using real-time PCR and microscopy. The latter included the direct wet mount and formalin-ether concentration technique (FECT). The infection load in FECT-positive samples was determined by the Kato-Katz method. Rotorgene real-time analyzer detected five helminth species using two sets of assays. Results: The real-time PCR detected soil-transmitted helminth in 98.4% samples (n=122), which were 1.56 times higher than by microscopy. Ascaris lumbricoides and Trichuris trichiura were detected in more than 90% of the samples, while hookworm was detected in 46.7% (Necator americanus) and 13.9% (Ancylostoma sp.) of the samples. Comparison with previous reports on the Malaysian aborigines showed that the real-time PCR markedly improved the detection of Ascaris lumbricoides, hookworm and Strongyloides stercoralis. The real-time PCR detected poly-helminths in 92.6% of the samples compared to 28.7% by microscopy. In addition, 27 samples (22.1%) showed amplification of Strongyloides stercoralis DNA. Conclusions: The real-time PCR showed very high prevalence rates of soil-transmitted helminth infections in the aborigines and is the recommended method for epidemiological investigation of soil-transmitted helminth infections in this population.

Fermentation of mulberry leaves with Cordyceps militaris enhanced anti-adipogenesis activity in 3T3-L1 cells through down-regulation of PPAR-γ pathway signaling Lu Guo, Jum Soon Kang, Young Hoon Park, Beong Il Je, Dae Youn Hwang, Woo Hong Joo, Young Whan Choi Asian Pacific Journal of Tropical Medicine 2020 13(12):557-565 Objective: To establish an efficacious and efficient fermentation method of enhancing the anti-adipogenesis effect of mulberry (Morus alba) leaves using Cordyceps militais. Methods: Dried mulberry leaves, dried mulberry leaves with 50% raw silkworm pupa and raw silkworm pupa were fermented with Cordyceps militais for 4 weeks at 25 °C, after which the dried mulberry leaves and fermented product were extracted with 70% ethanol and subjected to high performance liquid chromatography (HPLC). The contents of cordycepin, pelargonidin, chlorogenic acid, iso-quercetin and caffeic acid were determined. We then used the 3T3-L1 cells to investigate whether extracts of fermentation enhanced anti-adipogenesis activity in vitro. Results: HPLC showed that fermentation changed the contents of cordycepin, pelargonidin, chlorogenic acid, iso-quercetin and caffeic acid. Furthermore, fermented dried mulberry leaves with 50% raw silkworm pupa had a better efficacy of anti-adipogenesis than dried mulberry leaves, fermented dried mulberry leaves and fermented silkworm pupa and inhibited triglycerides accumulation and glucose consumption. Additionally, fermented dried mulberry leaves with 50% raw silkworm pupa inhibited PPAR-γ signaling. Conclusions: Fermentation with Cordyceps militaris enhanced anti-adipogenesis efficacy of mulberry leaves.

In vitro efficacy of new synthetic benzimidazole-related compounds against Schistosoma mansoni adult worms Amira Taman, Samia El-Bardicy, Menerva Tadros, Magda Ayoub, Basem Mansour, Fouad El-Shehabi, Samar N El-Beshbishi Asian Pacific Journal of Tropical Medicine 2020 13(12):566-572 Objective: To evaluate the in vitro antischistosomal activity of two new synthetic benzimidazole-related compounds: NBTP-OH and NBTP-F. Methods: Schistosoma adult worms were recovered from mice infected with Schistosoma mansoni cercaria, washed and then incubated in the culture media with different concentrations of compounds NBTP-OH and NBTP-F up to 72 h. Scanning electron microscopy was conducted to report morphological changes. Results: Incubation of adult Schistosoma mansoni with 10 μg/mL of NBTP-OH for 48 h killed 81.25% of worms. The calculated LC50 and LC90 72 h post-incubation were 6.8 μg/mL and 9.8 μg/ mL, respectively. Exposure of worms to 10 μg/mL of NBTP-F killed 89.5% of worms after 48 h, mostly males (83.3%), the LC50 and LC90 after 72 h of incubation were 4.8 μg/mL and 6.9 μg/mL, respectively. Worms incubated for 72 h with these compounds revealed swelling and deformity of oral sucker, disorganization and erosion of the tegument when examined with scanning electron microscopy. Conclusions: NBTP-OH and NBTP-F possess in vitro antischistosomal activities; however, in vivo studies should be conducted to examine their antischistosomal effects.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Hazardous Materials

Possible application of stable isotope compositions for the identification of metal sources in soil Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): Liuwei Wang, Yuanliang Jin, Dominik J. Weiss, Nina J. Schleicher, Wolfgang Wilcke, Longhua Wu, Qingjun Guo, Jiubin Chen, David O'Connor, Deyi Hou

Biochar for simultaneously enhancing the slow-release performance of fertilizers and minimizing the pollution of pesticides Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): Xiongfang An, Zhansheng Wu, Wen Shi, Huihua Qi, Luohong Zhang, Xiaolin Xu, Bing Yu

Nitrogen-doped porous biochar derived from marine algae for efficient solid-phase microextraction of chlorobenzenes from aqueous solution Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): Rongting Ji, Yarui Wu, Yongrong Bian, Yang Song, Qian Sun, Xin Jiang, Longjiang Zhang, Jiangang Han, Hu Cheng

Pre-coagulation with cationic flocculant-composited titanium xerogel coagulant for alleviating subsequent ultrafiltration membrane fouling by algae-related pollutants Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): Min Xu, Xiaomeng Wang, Bo Zhou, Lixiang Zhou

Methane-associated micro-ecological processes crucially improve the self-purification of lindane-polluted paddy soil Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): Jing Yuan, Jue Shentu, Jiaying Feng, Zhijing Lu, Jianming Xu, Yan He

Enhanced adsorptive removal of sulfamethoxazole from water using biochar derived from hydrothermal carbonization of sugarcane bagasse Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): G. Prasannamedha, P. Senthil Kumar, R. Mehala, T.J. Sharumitha, D. Surendhar

Adsorption behaviors of the pristine and aged thermoplastic polyurethane microplastics in Cu(II)-OTC coexisting system Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): Xiang-Dong Xue, Cheng-Ran Fang, Hai-Feng Zhuang

Toxic effects of naturally-aged microplastics on zebrafish juveniles: A more realistic approach to plastic pollution in freshwater ecosystems Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): Abraão Tiago Batista Guimarães, Ives Charlie-Silva, Guilherme Malafaia

Staged assessment for the involving mechanism of humic acid on enhancing water decontamination using H2O2-Fe(III) process Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): Bo Yang, Xin Cheng, Yongli Zhang, Wei Li, Jingquan Wang, Zixin Tian, Erdeng Du, Hongguang Guo

Enhanced photocatalytic degradation of glyphosate over 2D CoS/BiOBr heterojunctions under visible light irradiation Publication date: 5 April 2021 Source: Journal of Hazardous Materials, Volume 407 Author(s): Qiang-Yong Tang, Man-Jie Yang, Si-Yuan Yang, Yue-Hua Xu

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Otology

Middle ear mucosal compartm Mahendra Kumar Taneja Indian Journal of Otology 2020 26(3):115-121 Mucosal folds of middle ear are not a significant barrier in spread of infection cholesteatoma spread towards the least resistance and usually follow the folds. The mucosa of the middle ear is continuous with that of the pharynx via Eustachian tube. It covers the ossicles, muscles, nerves and forms the inner layer of tympanic membrane. Mucosal fold are of two types Composite Fold – these are of ligament with lining mucosa. Duplicate Fold – Fusion of two expanding sacs in absence of any interposing structure. Epitympanic Diaphragm it is an oblique dividing septum between the posterior superior attic and anteroinferior mesotympanium. It comprises of anterior malleolar ligament, lateral malleolar ligament, posterior malleolar ligament, lateral incudal fold, tensor tympani fold and posterior incudal ligament fold. Tympanic Isthimus is 2.5 mm elongated narrow space in epitympanic diaphragm present naturally and provides ventilation. Key message is tensor tympani fold and anterior Pouch of VonTroltsch is responsible for ventilation of anterior compartment. It is extremely important to understand and restore the functional anatomy, proper gas exchange and mucosal clearance from the middle ear compartment. The obstruction site is at tympanic isthimus. It is crucial to visualise and clearance of disease to restore ventilation. In surgical procedures of ear just removal of tensor tympani fold along with resection of Cog provides good results by providing ventilation of attic, mastoid air cells and a successful tympanoplasty.

Speech recognition in noise in patients with type II diabetes Somayeh Falahzadeh, Sima Tajik, Faezeh Azadi, Farnoosh Farjadi Indian Journal of Otology 2020 26(3):122-126 Context: The chronic diabetes is associated with damage to the sensory and cognitive regions brain. The central auditory system is susceptible to the damage caused by high glucose level. Aims: Since the healthy auditory system plays an important role in communication, this study examined speech recognition in noise performance of these people so as to better identify the harmful impacts of diabetes on the auditory processing. Settings and Design: This cross-sectional comparative study compares the speech recognition in noise performance of 30 diabetic patients and 30 normal individuals aged 30–55 years with quick speech in noise (Q-SIN) test. Subjects and Methods: All people had normal hearing and the speech recognition performance in silent, the Persian version of the Q-SIN test was used. Statistical Analysis Used: Results of signal-to-noise ratio loss (SNR loss) and recognition of words at different SNR levels were analyzed with Chi-square test and independent t-test in two groups. Results: There was a significant difference between diabetic patients and normal individuals in mean of SNR loss (P < 0.05). The comparison of word recognition scores in each SNR showed no significant difference in 25, 20 SNRs between the two groups (P > 0.05), but the performance of diabetic patients was weaker in 15, 10, 5, 0 SNR (P < 0.05). Conclusions: In the absence of hearing loss, the diabetic patients have a significant speech perception disorder, especially at lower levels of SNRs, compared to normal people of the same age. Impaired speech comprehension in the presence of a competitive message can result from the damage to central auditory processing as a result of diabetes.

Auditory brainstem response to level-specific CE-CHIRP® threshold estimation in normal-hearing adults Ahmad Aidil Arafat Dzulkarnain, Suhaila Ahmad Shuckri, Noraidah Ismail Indian Journal of Otology 2020 26(3):127-131 Background: The aim of the present study was to compare the hearing thresholds between pure tone audiometry (PTA) and auditory brainstem response (ABR) from level-specific (LS) CE-Chirp® and click stimuli in normal adult subjects. Materials and Methods: Twenty-four adults with normal audiometric thresholds participated in the study. The ABR was recorded from the study participants at 80 dBnHL until their respective auditory thresholds using both the LS CE-Chirp® and click stimuli. Study Design and Statistical Analysis: A quasi-experimental study design was used. Audiometric thresholds (low frequencies [LFs], mid frequencies [MFs], and high frequencies [HFs]) and the ABR thresholds from both stimuli were compared using the Friedman test with Wilcoxon signed-rank test as the post hoc analysis. Results: No statistically significant difference was identified between the PTA and the ABR to LS CE-Chirp® thresholds at LFs and only small differences (<6 dB) median thresholds differences were identified at the MFs and HF. The amplitudes of wave III and V were larger for ABR to LS CE-Chirp® as compared to the ABR from the click stimulus. Conclusion: This study concluded that the ABR to LS CE-Chirp® has closer thresholds than the audiogram as compared to the ABR from click in normal-hearing adult subjects. At the suprathreshold (80 dBnHL), the ABR amplitudes of wave III, and V were larger in LS CE-Chirp® than the click stimulus.

Vestibular evaluation in patients with congenital profound hearing loss using ice cold water caloric test and rotational chair test Arun Dehadaray, Viraj Gaikwad, Maitri Kaushik, Prasun Mishra, Sai Belsare Indian Journal of Otology 2020 26(3):132-134 Introduction: With the introduction of newborn hearing screening, hearing problems are often detected at the neonatal stage and in early infancy, and holistic approach including not only auditory but also vestibular function is needed. This study hopes to establish some corelation between cochlear and vestibular system dysfunction in a patient born with congenital profound hearing loss (CPHL). Materials and Methods: In this observational and descriptive study conducted at a tertiary care hospital, we evaluated eighty patients with bilateral CPHL from 2016 to 2018. After taking a detailed history and thorough ear, nose, and throat examination, the patients underwent vestibular function evaluation by ice cold water caloric test (ICCT) and rotational chair test (RCT) in the outpatient department, and the duration of nystagmus was calculated based on which hypoactive or absent vestibular function was found out. Results: In the present study, out of eighty patients with CPHL, vestibular function of 62 (77.50%) was normal, 9 (11.25%) hypoactive, and 9 (11.25%) with absent vestibular function. Conclusion: In the outpatient department where sophisticated equipment and laboratory facilities are not available, ICCT can be used to determine the vestibular function and also RCT can be used. From the present study, it can be concluded that vestibular dysfunction is present in 22.50% of patients with CPHL with the use of ICCT and RCT. There is a strong possibility of genetic origin etiology for vestibular dysfunction. The present study also concludes that consanguinity may be major etiological factor for vestibular dysfunction.

Influence of cardiovascular risk factors on cochlear dysfunction Nemanja Radivojevic, Nenad Arsovic, Zoran Dudvarski, Vladimir Nesic, Ljiljana Cvorovic, Snezana Babac, Aleksandra Radivojevic Indian Journal of Otology 2020 26(3):135-140 Background: Cochlear dysfunction can arise not only from various factors such as ear diseases but also from systemic disorders of the body. The occurrence of otologic symptoms such as hearing loss, dizziness, and tinnitus can be due to cardiovascular disorders. Therefore, current understandings in the field of the diagnosis and therapy of cardiovascular diseases (CVDs) should include, among others, evidence of otologic disorders. Objective: The aim of this study is to determine the association between risk factors for CVD and cochlear dysfunction. Methods: The cross-sectional study included 128 participants with major CVD risk factors who underwent auditory function examination (pure tone audiometry). Results: There were 52 women (40.6%) and 76 men (59.4%) in total. The mean age of the participants was 58 years (a range of 28–83 years). The mean age among participants with hearing loss was 60 (±10.88), whereas the mean age among participants that had normal hearing thresholds was 54 (±12.18). Sensorineural hearing loss (SNHL) was measured in 59% of participants, of most frequent mild degree hearing loss. The prevalence of SNHL was higher in participants with arterial hypertension (P < 0.001, OR = 5.881, 95% CI 2.694–12.837) and the most common among them was moderate degree hearing impairment (38%). There is also a statistically significant association of SNHL with dyslipidemia and elevated body mass index (P < 0.001, [OR]: 4.118, 95% [CI]: 1.873–9.053 and P< 0.001, [OR]: 1.517, 95% [CI]: 1.237–1.859 ) with moderate and profound hearing loss. Conclusion: Based on the data obtained, it seems that the presence of major cardiovascular risk factors was a significant predictor for cochlear dysfunction.

Examination of ototoxicity induced by imatinib, being a tyrosine kinase inhibitor: An experimental study Emine Elif Altuntas, Kasim Durmus, Adem Bora, Nergiz Hacer Turgut, Hatice Terzi, Ahmet Kutluhan Indian Journal of Otology 2020 26(3):141-146 Objectives: Two rats were excluded from the study. Because otitis media developing one rat in Group C (7th dayof the experiment) and bleeding-related death one rat in Group I-50 (14th day of the experiment). While the side effects of imatinib are investigated in the literature, it is remarkable that the case reports suggesting an ototoxic side effect also take place among the publications. The aim of this study was to investigate whether or not imatinib has any ototoxic effect on rats via auditory brainstem response (ABR) responses. Materials and Methods: Rats were divided into three groups as Group C (0.25 mL/kg/day), Group I-30 (30 mg/kg/day), and Group I-50 (50 mg/kg/day). In the ABR record, hearing threshold, latency, amplitude, and interpeak latency values on test days were recorded and assessed. Results: In the assessment made in terms of mean V Wave latency within the group, a difference was determined at all stimulus intensities at 8 kHz in Group I-50 (P < 0.05). In the within-group assessment performed in terms of mean Wave III latency, there were differences in Groups I-30 and I-50 (P < 0.05). In the within-group assessment performed in terms of I–III interpeak latency mean values, there was a difference at 4 kHz and 70 dB in Group I-30 (P < 0.05). In the within-group assessment in terms of mean III–V interpeak latency values, the difference between the groups was significant on the 7th day at 6 kHz and 50 dB (P = 0.044) and on the 14th day at 8 kHz and 70 dB (P = 0.036). In the within-group assessment in terms of Wave I amplitude mean values, the change in the amplitude values at 4 kHz (P = 0.003) and 6 kHz (P = 0.018) in Group I-50 was significant. Conclusion: It was observed that imatinib application caused elongation in latency and interpeak latency values and changes in amplitude values. These differences were not enough to state that imatinib is having an ototoxic side effect.

Vestibular epilepsy: Clinical presentation, diagnosis, and management Ajay Philip, GR Haripriya, Manju Deena Mammen, Anjali Lepcha, Ann Mary Augustine Indian Journal of Otology 2020 26(3):147-150 Background: Vestibular epilepsy as a cause of vertigo is rare. This clinical entity occurs primarily due to epileptic activity in parts of the cortex that represents the vestibular system. It is often distinctive with sudden, brief episodes of vertigo followed by rapid recovery without sequelae. In vestibular epilepsy, vertigo is not simply an aura, but constitutes a part of the seizure, and maybe its only manifestation. Aim: The aim of this study was to describe the clinical profile of patients diagnosed with vestibular epilepsy who presented to the neurotology clinic in our hospital in the past 7 years from January 1, 2014, to May 1, 2020, and to present their clinical features, diagnosis, and management. Materials and Methods: This was a retrospective observational clinical study based on the medical records of all patients diagnosed with vestibular epilepsy who presented during the period January 1, 2014–May 1, 2020, to our neurotology clinics. Each patient's history and neurotological examination were documented. All investigations carried out such as audiovestibular tests, electroencephalogram, cardiac tests, and imaging were noted. Results: Ten patients were diagnosed with vestibular epilepsy in our clinic during this time period, with a prevalence of vestibular epilepsy being 0.001%. The main subjective aura in our patients was vestibular disturbance in the form of rotatory type of vertigo which lasted for a few seconds. These symptoms were followed by abnormal movements of limb and loss of consciousness (LOC) in six patients. The patients who experienced a LOC had cardiology workup. Electronystagmogram was abnormal in three patients, while magnetic resonance imaging showed an abnormality in three patients. All patients were started on anticonvulsant drugs and showed a good response to treatment. Conclusion: Vestibular epilepsy is a rare but treatable cause of transient dizziness. The diagnosis of vestibular epilepsy is often missed or delayed and should be considered when brief episodic spontaneous vertigo occurs with LOC and unresponsive to standard vestibular treatment. Treatment with anticonvulsants seems to give relief of symptoms.

Efficacy of medical grade manuka honey in acute otitis externa: A pilot study Amit Kumar, Shweta Mittal, Amit Kumar Tyagi, Hano Romesh, Saurabh Varshney, Manu Malhotra Indian Journal of Otology 2020 26(3):151-154 Introduction: Manuka honey has been used in chronic diabetic ulcers and traumatic wounds. We have used Manuka honey in cases of otitis externa because of its antibacterial and anti-inflammatory properties. Objectives: The objective was to study the efficacy of topical applications of Manuka honey in the patients of acute otitis externa. Materials and Methods: Patients with acute otitis externa without any prior ear complaint or intervention were selected for the study after informed and written consent. All patients selected for the study were packed with Manuka honey-impregnated umbilical tape and pain scores; canal wall edema was recorded on days 0, 1, 3, and 7. Results: A total of 20 patients were included in our study. Twenty patients followed us on day 1, 15 patients on day 3, and seven patients followed us till day 7. The mean pain score for day 0 was 5.35, and the mean pain score decreased to 2.95 on day 1, and the difference was statistically significant. Conclusion: Manuka honey appears to be an effective therapeutic agent in the management of otitis externa.

Effect of middle ear surgery on taste in patients with chronic otitis media Vijin Ravindran, Deviprasad Shetty, K S Gangadhara Somayaji Indian Journal of Otology 2020 26(3):155-158 Objective: The objective was to identify the gustatory changes in patients with chronic otitis media due to chorda tympani nerve involvement and to identify the gustatory changes with minimal manipulation, stretching, and cutting of the nerve during surgery and its postoperative recovery. Methodology: A total of 100 patients were selected. Clinical assay, with tests based on “taste strips” with different concentrations of salt, sweet, bitter, and sour, was done preoperatively. The taste strips used were sodium chloride for salt, sucrose for sweet, quinine sulfate for bitter, and citric acid for sour. The same was tested postoperatively after 1 week, 1 month, and 6 months. Analysis: Of the total 100 patients, 22 patients had squamosal disease, and the remaining 78 patients had mucosal disease. Fourteen patients were found to have taste changes preoperatively, of whom nine recovered their taste 1 week following surgery. Remaining five patients recovered at 1 month following the surgery. It was also observed that, in all the 25 patients where the nerve was cut, postoperative changes were noted, which recovered completely at the end of 6 months, except in two patients. In patients where the nerve was stretched, patients showed more gustatory alterations when compared with patients where the nerve was minimally manipulated. Conclusion: We conclude from our study that cutting the nerve produced less gustatory alterations, when compared with patients where the nerve was stretched. We also concluded that chronic inflammation of the middle ear itself can cause gustatory alterations, and these changes recovered once the disease was cleared.

Assessment of vestibulotoxicity of neem leaf (Azadirachta indica) in a rat animal model Rosdan Salim, Mohd Khairi Md Daud, Maithrea Suresh Narayanan, Aziah Ab Rani Indian Journal of Otology 2020 26(3):159-162 Introduction: Otomycosis is a challenging and frustrating entity for both patients and otolaryngologists for it frequently requires long-term treatment and follow-up, yet the recurrence rate remains high. The management is directed toward intense aural toileting with administration of topical antifungals. There has been increased resistance to classical antifungal agents, typically involving the azoles and polyenes. This has led into the research of medicinal plants as an alternative treatment for treating fungal infections. Objective: This study aims to investigate the possible vestibulotoxic effects of neem leaf (Azadirachta indica), a commonly used home remedy on the inner ear in a rat animal model. Methodology: Twenty healthy, mature Wistar albino rats were divided into three groups: Groups A (eight animals), B (eight animals), and C (four animals). They underwent baseline vestibular parameter testing, following which an endoscopic-guided transtympanic instillation of aqueous and alcohol neem extract was performed into the right middle ear of the rats in Groups A and B, while normal saline was instilled into the right middle ear of rats in Group C. Vestibular parameter testing was repeated on the rats in both groups post instillation of transtympanic neem at 4-h, 24-h, 48-h, 72-h, 1-week, 2-week, and 3-week intervals. Results: There was no deterioration in all vestibular parameters recorded post instillation of neem extract within the middle ear. Conclusion: Neem extract is a safe alternative in the treatment of otomycosis in the presence of tympanic membrane perforation as it poses no vestibulotoxic side effects.

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Acta Medica International

Romosozumab: A new anabolic arrow in quiver for management of osteoporosis Alok Singh, Dhyuti Gupta Acta Medica International 2020 7(2):57-62 The multifactorial disease of the elderly, characterized by accelerated bone loss and a high risk of fracture (even with trivial trauma), osteoporosis, is known to primarily affect postmenopausal women. Moreover, the precipitating factors for the same mainly are the hormonal and nutritional deficiency. Clinically, the most common fracture to be encountered is the vertebral compression fracture. Apart from exogenously supplementing calcium and Vitamin D, a diverse group of drugs (bisphosphonates, denosumab, teriparatide, strontium ranelate, raloxifene, and calcitonin) are available to manage the case of osteoporosis. The latest drug to be approved and included in this quiver is a sclerostin-targeting monoclonal antibody, romosozumab. This new drug appears to be promising in managing the postmenopausal patients of osteoporosis. Although the array of adverse effects is not well recognized, a black box warning has been issued for this drug in reference to contraindicated use in patients with comorbid myocardial infarction. The intent of the authors for this review is to discuss the pharmacological profile of romosozumab, with particular emphasis on supportive clinical trials as well as the adverse drug reactions associated with its use.

Laboratory findings in COVID-19 patients and biomarkers for early assessment of severity and mortality Asbah Shams, Madhu Sinha, Abhijit Das, Natasha Gulati, Rani Sahu, Man Mohan Mehndiratta, Chandra Shekhar Acta Medica International 2020 7(2):63-68 The novel coronavirus-19 (severe acute respiratory syndrome coronavirus-2) pandemic has crossed more than 4,006,257 cases with 278,892 deaths worldwide and 67,152 cases and 2206 deaths in India. The disease has a variable clinical course ranging from mild to severe disease. Although most of the patients are asymptomatic, some patients with comorbidities have a high propensity of clinical worsening and mortality and it is this chunk of patients that we need to recuperate. Studies have shown that a number of laboratory parameters, which are easily available and inexpensive, can adequately predict the disease severity at an early stage. In a resource-limited country like India, where costly investigations cannot be routinely carried out in the magnitude as big as that of this pandemic, it is imperative that patients be monitored with these simple and inexpensive parameters that are elucidated in this review. We carried out an electronic search on PubMed and Google Scholar with keywords “laboratory abnormalities in COVID-19,” “coagulopathy in COVID-19,” “sepsis in COVID-19,” “hematologic abnormalities in COVID-19,” “kidney injury in COVID-19,” “acute respiratory distress syndrome in COVID-19,” “cardiac injury in COVID-19,” “liver injury in COVID-19,” and “severity indicators in COVID-19” till present date (May 11, 2020). All studies that appeared in our search results were scrutinized and 40 studies were selected for the study.

Dissatisfaction and problems in marital life of spouses of patients with bipolar disorder: A cross-sectional study from a tertiary care hospital Bilal Ahmad Bhat, Rouf Ahmad Mir, Arshad Hussain, Iqra Rasheed Shah Acta Medica International 2020 7(2):69-75 Introduction: The objective was to understand the marital dissatisfaction/satisfaction and problems in different areas of marital life in spouses of patients with bipolar disorder (BD). Materials and Methods: In this cross sectional descriptive study on BD patients and their spouses, a semi structured questionnaire was used to collect sociodemographic details. Couple satisfaction index (CSI) was used to identify marital satisfaction or dissatisfaction, whereas problem areas questionnaire (PAQ) was used to identify areas in which spouses of BD patients were often dissatisfied or have disagreements about their partner's behavior. Results: A total of 170 BD patients, along with their spouses, were included in our study. Marital dissatisfaction was present in 104 (61.2%) and there was no significant relation with sociodemographic variables except for the number of children (P = 0.002). Mean scores on CSI and PAQ were 42.75 ± 17.32 and 28.91 ± 11.28, respectively, with a significant negative correlation between these (r =-0.712; P = 0.0001). Handling family finances; rearing children or parenting, career/job related decisions, demonstrations of affection, handling household tasks, spending recreation leisure time together, moodiness/temper/emotionality, and problems in sex relations were important areas in which partners of BD patients were facing a significant problem. Conclusions: Marital dissatisfaction was very common in spouses of BD patients and they faced a lot of problems in various areas of their lives. As clinicians, we need to evaluate and understand the issues related to the marital life of normal spouses of BD patients to provide emotional and practical support to them, individually as well as couples.

Awareness and attitude about heart transplantation among undergraduate nursing students: An institution-based survey in India Suresh K Sharma, Hemlata Sadhanu, Manisha Naithani, Anshuman Darbari, Jyoti Bharadwaj, Maneesh Sharma Acta Medica International 2020 7(2):76-80 Introduction: Heart transplantation is the currently available and established lifesaving therapy for the end stage heart failure. Considering the paucity of data about nurses' awareness and attitude about heart transplantation, this survey was undertaken. The aim of this study was to assess the awareness and attitude regarding heart transplantation among undergraduate nursing students. A questionnaire based cross sectional survey was conducted among undergraduate nursing students studying in an institute of national importance in India. Materials and Methods: A prevalidated questionnaire was administered among 147 randomly selected participants who were willing to participate in the study. Results: All the students (100%) were aware about organ donation, but majority (77.5%) informed that their source of information on this topic is by Internet/media. Around 18.4% of participants had already pledged permission for organ donation after death and 70.8% were willing to donate the organ after death. Conclusion: Results showed the gap existence and need of addressing this among undergraduate nursing students regarding organ donation and heart transplantation.

Selfitis, narcissism, and emotional intelligence: Eliciting the interrelation among medical students in Kolkata, West Bengal Soumalya Ray, Tanmay Kanti Panja, Dipta Kanti Mukhopadhyay Acta Medica International 2020 7(2):81-85 Introduction: Selfitis, the obsessive behavior to take and share one's own photographs, is a popular activity among young adults. It is growing with the availability of cheap data and free social network services. Scientific literature considers it as an effort to emphasize self-importance in the context of inadequate social support. The aim was to assess the burden of selfitis among medical students and to identify factors associated with it. This cross-sectional study was conducted among 166 students of a medical college in Kolkata, from December 2019 to March 2020. Materials and Methods: The level of selfitis was assessed using the Selfitis Behavior Scale (SBS). Narcissism was evaluated using Narcissistic Personality Inventory-16 and emotional intelligence (EI) was assessed using the mind tool EI questionnaire. Quantitative data were expressed as mean (±standard deviation) or median (±interquartile range) and qualitative data were expressed in frequency and percentage. Binary logistic regression was done with the level of selfitis as a dependent variable and narcissistic trait, EI, and other sociodemographic, individual characteristics as the independent variable. Results: Around one-third (35.5%) of the respondents had borderline selfitis according to SBS. None of the respondents had acute or chronic selfitis. Perceived presence of recreational activity (adjusted odds ratio [AOR] - 15.71), availability of pocket money (AOR - 69.42), family support (AOR - 6.30), and narcissistic trait (AOR - 3.94) were positively associated with borderline selfitis. Conclusions: Around one-third had borderline selfitis. Narcissism and lack of perceived family support were found to be associated with it.

Impact of COVID 19 lockdown on the study of medical students: A cross sectional survey Jolly Agarwal, Sonam Maheshwari, Anurag Agrawal, MK Pant, Yatika Chaudhary, Manisha Naithani Acta Medica International 2020 7(2):86-89 Introduction: During the pandemic of COVID 19, the traditional teaching of MBBS students has been shifted to online teaching. We conduct an online survey to know and record the impact of COVID 19 lockdown on the study of medical students of GDMC, Dehradun. The present study aimed to investigate the MBBS student's perception of online teaching. The results of this study may provide further inputs which might be of help to the students and faculty for further informed decisions. Materials and Methods: A cross sectional online survey during July 1–7, 2020 was applied to 334 medical students to evaluate the perception of online teaching among medical students. A questionnaire was prepared in Google form and divided into two sections. The first part covered demographics information of the respondent and the second part assessed with behavior and attitude toward online teaching. Results: The mean assessment, behavior, and attitude scores have significantly differed across age groups and previous experience. The medical students who had no exposure to online teaching their assessment score is higher than who had little exposure also found to be significant. The participants were agreed with the teaching way of the course (59.3%) and with the content of the course (56.9%). Majority of participants (58.4%) also agree that there are barriers in online learning. Most of the students agree (62.3%) and strongly agree (61%) that the course allowed them to take responsibility for their learning. Conclusions: We can conclude that the online learning program is a good alternative to classroom teaching in this era of the COVID 19 pandemic. This study can provide the basic architecture for making further strategy of course content.

Prevalence of temporomandibular disorders in individuals seeking treatment at dental hospital: A cross-sectional study Varsha Kanjani, Neel Gupta, Akash Bhatt, Mehak Tariq, Ajaz Ahmed, Kanchan Malawat Acta Medica International 2020 7(2):90-92 Introduction: Temporomandibular disorders (TMDs) being the most prevalent orofacial condition, is one of the major reason for patients to seek conservative intervention at dental hospital. The multifactorial etiology of TMDs along with the wide spectrum of associated signs and symptoms, mainly orofacial pain, restricted mouth opening, and deviation, has made the condition difficult to diagnose. The aim of the present study is to determine the signs and symptoms associated with temporomandibular disorders according to Research Diagnostic criteria for Temporomandibular disorders (RDC/TMD). Materials and Methods: The present cross-sectional study was conducted at dental hospital, Rajasthan among 1450 individuals. The 209 individuals, above 18 years of age who met the inclusion criteria were enrolled in the study. Along with signs and symptoms of TMDs (VAS score for orofacial pain, clicking sound, crepitus, reduced mouth opening (less than 40 mm), joint deviation and tenderness, etc.) the structured questionnaire according to RDC/ TMD were also assessed. The data was analyzed using Statistical Package for the Social Sciences version 21 software. Results: In the present study population, the prevalence of TMDs was 14.41% only. Most of the patients were in 2nd decade (33.01%) with female predilection (69.85%). The VAS score for patients complaining of orofacial pain (58.85%) was 6.32±1.12 with reduced mouth opening in 42.58%. According to RDC/TMD, the most common finding observed was TM joint deviation (63.15 %), followed by clicking sound (56.93%), crepitus (46.41%), MPDS (12.91%), internal derangements (10.52%) and osteoarthritis (6.22%). Conclusion: The prevalence of TMDs was more prevalent in younger generation, especially with female predilection. The most common signs and symptoms seen in the present study were orofacial pain, followed by reduced mouth opening, TMJ deviation and clicking sound.

Cord blood lactate levels as marker for perinatal hypoxia and predictor for hypoxic ischemic encephalopathy Ashish Kumar Simalti, Vandana Negi, Anil Kumar, Suman Kumar Pramanik Acta Medica International 2020 7(2):93-96 Introduction: This study was conducted to find if cord blood lactate correlates well with Apgar score and umbilical cord blood pH and subsequent development of hypoxic ischemic encephalopathy (HIE). Materials and Methods: It was a cross sectional, observational study which was conducted at a tertiary care referral center of North India from June 2018 to June 2019. Monitoring of cord blood lactate levels along with Apgar and cord blood pH was done for correlation of cord blood lactate with Apgar, cord blood pH, and subsequently development of HIE. Results: During the study period, 115 term neonates got enrolled based on inclusion criteria. Out of these, 83 babies had some degree of HIE based on Sarnat staging. Among these 83 neonates with encephalopathy, 36 had Stage III HIE while, 28 and 19 babies had Stage II and Stage I encephalopathy, respectively. Lactate levels correlated negatively with Apgar score and umbilical cord blood pH and higher levels of lactate correlated well with lower Apgar and cord blood pH. The mean lactate level was significantly higher in cases with HIE (5.18 mmol/L) as compared to cases without HIE (2.91 mmol/L). Conclusion: Our study shows that cord blood lactate can be used as a predictor for perinatal hypoxia. With the availability of cheaper handheld lactate monitors, lactate monitoring may become more practical option and need to be explored.

Treatment outcome of percutaneous nephrolithotomy: The initial experience from a tertiary care Center Ifrah Ahmad, Irshad Ahmad, Arif Hamid, Erum Khateeb Acta Medica International 2020 7(2):97-101 Introduction: The purpose of the study was to assess the operative characteristics and treatment outcome of percutaneous nephrolithotomy (PCNL) for the treatment of renal calculi at our hospital. Materials and Methods: Patients with significant size symptomatic renal calculi not manageable by conservative management and those with calculi resistant to extracorporeal shock wave lithotripsy (ESWL) were included in the study. Patients excluded from the study were those with significant coagulopathy, active upper urinary tract infection, and renal calculi in ectopic kidneys. Results: Our study group had a mean age of 42.46 ± 11.29 years. Nearly 60% of stones in our study were of size 21–30 mm in the longest diameter with mean stone diameter of 24.56 ± 7.809 mm. Mean hemoglobin drop following the procedure was 1.35 ± 0.843 g/dl. Mean operative time was 93.56 ± 9.90 min. We had an overall success rate of 83.5% in our study. Fourteen failure cases were managed by ESWL (ten cases), second look PCNL (three cases), and by open surgery (one case). Conclusion: Although we find a higher frequency of minor complications such as transient mild hematuria (37.6%), mild puncture site pain (55.3%), or low-grade fever (24.7%), no major or long-term side effects were observed in our series.

Infectious granulomatous dermatitis: Clinicohistopathological study with some unusual clinical presentation Praneeta Jaswant Singh, Ambrish Kumar Acta Medica International 2020 7(2):102-107 Introduction: Granulomatous dermatitis has a varied differential diagnosis ranging from infectious etiology to immune mediated diseases. In tropical countries like India, infectious etiology forms an important cause of granulomatous dermatitis with tuberculosis (TB) and leprosy being the major contributing factors. The present study was carried out with the aim to determine the frequency of various etiological agents causing infectious granulomatous dermatitis in our hospital setup and to see clinicohistopathological correlation in these cases. Materials and Methods: This is a hospital based retrospective study conducted in the department of pathology over a period of 1 year. All the skin biopsy cases diagnosed as infectious granulomatous dermatitis were retrieved from the histopathology record section for analysis and were categorized based on the causative etiological agents. Special stains were applied wherever necessary in addition to routine hematoxylin and eosin stain. Results: A total of 40 cases of infectious granulomatous dermatitis were included in the present study. Most common diagnosis was leprosy (57.5%), followed by TB (30.0%), actinomycosis (5.0%), dermatophytosis (2.5%), histoplasmosis (2.5%), and cysticercosis (2.5%). Gender wise distribution showed male predominance with 57.5% of cases and age wise distribution showed a peak in the age group of 41–60 years (32.5%). Clinicohistopathological correlation was found in 87.50% of the cases. The unusual clinical presentations were seen in cases of cysticercosis, actinomycosis, and histoplasmosis. Conclusion: Histopathological examination of the skin biopsies is an important diagnostic tool providing definitive diagnosis as well as clinicohistopathological correlation in cases of infectious granulomatous dermatitis.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Anaesthesiology

Treating patients across European Union borders: An international survey in light of the coronavirus disease-19 pandemic BACKGROUND In light of the coronavirus disease-2019 (COVID-19) pandemic, how resources are managed and the critically ill are allocated must be reviewed. Although ethical recommendations have been published, strategies for dealing with overcapacity of critical care resources have so far not been addressed. OBJECTIVES Assess expert opinion for allocation preferences regarding the growing imbalance between supply and demand for medical resources. DESIGN A 10-item questionnaire was developed and sent to the most prominent members of the European Society of Anaesthesiology and Intensive Care (ESAIC). SETTING Survey via a web-based platform. PATIENTS Respondents were members of the National Anaesthesiologists Societies Committee and Council Members of the ESAIC; 74 of 80 (92.5%), responded to the survey. MEASUREMENTS AND MAIN RESULTS Responses were analysed thematically. The majority of respondents (83.8%), indicated that resources for COVID-19 were available at the time of the survey. Of the representatives of the ESAIC governing bodies, 58.9% favoured an allocation of excess critical care capacity: 69% wished to make them available to supraregional patients, whereas 30.9% preferred to keep the resources available for the local population. Regarding the type of distribution of resources, 35.3% preferred to make critical care available, 32.4% favoured the allocation of medical equipment and 32.4% wished to support both options. The majority (59.5%) supported the implementation of a central European institution to manage such resource allocation. CONCLUSION Experts in critical care support the allocation of resources from centres with overcapacity. The results indicate the need for centrally administered allocation mechanisms that are not based on ethically disputable triage systems. It seems, therefore, that there is wide acceptance and solidarity among the European anaesthesiological community that local medical and human pressure should be relieved during a pandemic by implementing national and international re-allocation strategies among healthcare providers and healthcare systems. Correspondence to Elisabeth H. Adam, MD, MHBA, Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany Tel: +49 69 6301 5868; fax: +49 69 6301 7695; e-mail: elisabeth.adam@kgu.de Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2020 European Society of Anaesthesiology

Chronic stress indicated by hair cortisol concentration in anaesthesiologists and its relationship to work experience and emotional intelligence: A cross-sectional biomarker and survey study BACKGROUND Anaesthesia is a stressful medical specialty. The reaction to stress is constituted by behavioural, psychological and physiological components. Chronic physiological stress can have negative consequences for health. OBJECTIVES First, we hypothesised that chronic physiological stress is higher for both beginning and late-career consultant anaesthesiologists. Second, we hypothesised that individuals high in emotional intelligence endure lower physiological stress. DESIGN Cross-sectional biomarker and survey study. SETTING Participants were recruited during the May 2019 annual meeting of the Dutch Anaesthesia Society. PARTICIPANTS Of the 1348 colleagues who attended the meeting, 184 (70 male/114 female) participated in the study. Of the study participants, 123 (67%) were consultant anaesthesiologists (52 male/71 female) and 61 (33%) were resident anaesthesiologists (18 male/43 female). Exclusion criteria were endocrine disorders and not having enough hair. Also, experience of a recent major life event led to exclusion from analysis of our hypotheses. MAIN OUTCOME MEASURES Chronic physiological stress was measured by hair cortisol concentration. Emotional intelligence was assessed using a validated Dutch version of the Trait Emotional Intelligence Questionnaire. As secondary measures, psychological sources of stress were assessed using validated Dutch versions of the home-work interference (SWING) and the effort-reward imbalance questionnaires. RESULTS In support of Hypothesis 1, hair cortisol concentration was highest among early and late-career consultant anaesthesiologists (quadratic effect: b = 45.5, SE = 16.1, t = 2.8, P = 0.006, R2 = 0.14). This nonlinear pattern was not mirrored by self-reported sources of psychological stress. Our results did not support Hypothesis 2; we found no evidence for a relationship between emotional intelligence and physiological stress. CONCLUSION In the early and later phases of an anaesthesiologist's career, physiological chronic stress is higher than in the middle of the career. However, this physiological response could not be explained from known sources of psychological stress. We discuss these findings against the background of key differences between physiological and psychological stress. Correspondence to Raymond A.B. van der Wal, Radboud University Nijmegen Medical Center, Department of Anaesthesiology, Pain and Palliative Medicine, Internal postal code 717, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands Tel: +31 24 361 4406; e-mail: Raymond.vanderwal@radboudumc.nl Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2020 European Society of Anaesthesiology

Hand or foot train-of-four tests and surgical site muscle relaxation assessed with multiple motor evoked potentials: A prospective observational study BACKGROUND Intra-operative muscle relaxation is often required in orthopaedic surgery and the hand train-of-four (TOF) test is usually used for its quantification. However, even though full muscle relaxation is claimed by anaesthesiologists based on a TOF count of zero, surgeons observe residual muscle activity. OBJECTIVE The aim of the study was to assess if hand or foot TOF adequately represents intra-operative muscle relaxation compared with multiple motor evoked potentials. DESIGN Prospective observational study. SETTING A single-centre study performed between February 2016 and December 2018 at the Balgrist University Hospital, Zurich, Switzerland. PATIENTS Twenty patients scheduled for elective lumbar spinal fusion were prospectively enrolled in this study after giving written informed consent. INTERVENTIONS To assess neuromuscular blockade (NMB) with the intermediate duration nondepolarising neuromuscular blocking agent rocuronium, hand TOF (adductor pollicis) and foot TOF (flexor hallucis brevis) monitoring, and muscle motor evoked potentials (MMEPs) from the upper and lower extremities were assessed prior to surgery under general anaesthesia. Following baseline measurements, muscle relaxation was performed with rocuronium until the spinal surgeon observed sufficient relaxation for surgical intervention. At this timepoint, NMB was assessed by TOF and MMEP. MAIN OUTCOME MEASURES The primary outcome was to determine the different effect of rocuronium on muscle relaxation comparing hand and foot TOF with the paraspinal musculature assessed by MMEP. RESULTS Hand TOF was more resistant to NMB and had a shorter recovery time than foot TOF. When comparing MMEPs, muscle relaxation occurred first in the hip abductors, and the paraspinal and deltoid muscles. The most resistant muscle to NMB was the abductor digiti minimi. Direct comparison showed that repetitive MMEPs simultaneously recorded from various muscles at the upper and lower extremities and from paraspinal muscles reflect muscle relaxation similar to TOF testing. CONCLUSION Hand TOF is superior to foot TOF in assessing muscle relaxation during spinal surgery. Hand TOF adequately represents the degree of muscle relaxation not only for the paraspinal muscles but also for all orthopaedic surgical sites where NMB is crucial for good surgical conditions. TRIAL REGISTRATION clinicalTrials.gov (NCT03318718). Correspondence to Michael Betz, MD, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland Tel: +41 44 386 1600; fax: +41 44 386 1269; e-mail: Michael.betz@balgrist.ch This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2020 European Society of Anaesthesiology

Effect of dexmedetomidine on Nociception Level Index-guided remifentanil antinociception: A randomised controlled trial BACKGROUND The effect of dexmedetomidine on Nociception Level Index (Medasense, Israel) antinociception to reduce intra-operative opioid requirements has not been previously investigated. OBJECTIVE We aimed to determine if low-dose dexmedetomidine would reduce remifentanil requirements during Nociception Level Index-guided antinociception without increasing complications associated with dexmedetomidine. DESIGN Double-blind randomised controlled trial. SETTING Two university teaching hospitals in Brussels, Belgium. PATIENTS American Society of Anesthesiologists 1 and 2 patients (n = 58) undergoing maxillofacial or cervicofacial surgery under propofol--remifentanil target-controlled infusion anaesthesia. INTERVENTIONS A 30 min infusion of dexmedetomidine, or equal volume of 0.9% NaCl, was infused at 1.2 μg kg−1 h−1 immediately preceding induction and then decreased to 0.6 μg kg−1 h−1 until 30 min before ending surgery. Nociception Level Index and frontal electroencephalogram guided the remifentanil and propofol infusions, respectively. MAIN OUTCOMES The primary outcome was the remifentanil requirement. Other outcomes included the propofol requirement, cardiovascular status and postoperative outcome. RESULTS Mean ± SD remifentanil (3.96 ± 1.95 vs. 4.42 ± 2.04 ng ml−1; P = 0.0024) and propofol (2.78 ± 1.36 vs. 3.06 ± 1.29 μg ml−1; P = 0.0046) TCI effect site concentrations were lower in the dexmedetomidine group at 30 min postincision and remained lower throughout surgery. When remifentanil (0.133 ± 0.085 vs. 0.198 ± 0.086 μg kg−1 min−1; P = 0.0074) and propofol (5.7 ± 2.72 vs. 7.4 ± 2.80 mg kg−1 h−1; P = 0.0228) requirements are represented as infusion rates, this effect became statistically significant at 2 h postincision. CONCLUSION In ASA 1 and 2 patients receiving Nociception Level Index-guided antinociception, dexmedetomidine decreases intra-operative remifentanil requirements. Combined frontal electroencephalogram and Nociception Level Index monitoring can measure dexmedetomidine's hypnotic and opioid-sparing effects during remifentanil-propofol target-controlled infusion anaesthesia. TRIAL REGISTRATIONS Clinicaltrials.gov: NCT03912740, EudraCT: 2018-004512-22. Correspondence to Sean Coeckelenbergh, Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Rue Lennik 808, 1070 Brussels, Belgium Tel: +32 25 55 39 19; e-mail: sean.coeckelenbergh@ulb.be Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2020 European Society of Anaesthesiology

Pectoral nerve blocks for breast surgery: A meta-analysis BACKGROUND Pectoral nerve blocks (PECS block) might be an interesting new regional anaesthetic technique in patients undergoing breast surgery. OBJECTIVE The aim of this meta-analysis was to investigate postoperative pain outcomes and adverse events of a PECS block compared with no treatment, sham treatment or other regional anaesthetic techniques in women undergoing breast surgery. DESIGN We performed a systematic review of randomised controlled trials (RCT) with meta-analysis and risk of bias assessment. DATA SOURCES The databases MEDLINE, CENTRAL (until December 2019) and clinicaltrials.gov were systematically searched. ELIGIBILITY CRITERIA All RCTs investigating the efficacy and adverse events of PECS compared with sham treatment, no treatment or other regional anaesthetic techniques in women undergoing breast surgery with general anaesthesia were included. RESULTS A total of 24 RCTs (1565 patients) were included. PECS (compared with no treatment) block might reduce pain at rest [mean difference −1.14, 95% confidence interval (CI), −2.1 to −0.18, moderate quality evidence] but we are uncertain regarding the effect on pain during movement at 24 h after surgery (mean difference −1.79, 95% CI, −3.5 to −0.08, very low-quality evidence). We are also uncertain about the effect of PECS block on pain at rest at 24 h compared with sham block (mean difference −0.83, 95% CI, −1.80 to 0.14) or compared with paravertebral block (PVB) (mean difference −0.18, 95% CI, −1.0 to 0.65), both with very low-quality evidence. PECS block may have no effect on pain on movement at 24 h after surgery compared with PVB block (mean difference −0.56, 95% CI, −1.53 to 0.41, low-quality evidence). Block-related complications were generally poorly reported. CONCLUSION There is moderate quality evidence that PECS block compared with no treatment reduces postoperative pain intensity at rest. The observed results were less pronounced if patients received a sham block. Furthermore, PECS blocks might be equally effective as PVBs. Due to mostly low-quality or very low-quality evidence level, further research is warranted. PROTOCOL REGISTRATION CRD42019126733. Correspondence to Priv.-Doz. Dr. med. Alexander Schnabel, Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer Campus 1A, 48149 Muenster, Germany. Tel: +49 251 47255; e-mail: alexander.schnabel@ukmuenster.de Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2020 European Society of Anaesthesiology

Efficacy of intra-operative administration of iron isomaltoside for preventing postoperative anaemia after total knee arthroplasty: A randomised controlled trial BACKGROUND Postoperative anaemia is common after total knee arthroplasty (TKA). Emerging evidence shows the beneficial effects of peri-operative iron supplementation in patients at risk of postoperative anaemia. OBJECTIVE To evaluate the efficacy of intra-operative administration of iron isomaltoside for the prevention of postoperative anaemia in patients undergoing TKA. DESIGN Randomised, controlled, double-blind, parallel-group study. SETTING A tertiary care teaching hospital; between 29 March 2018 and 16 April 2019. PATIENTS Eighty-nine patients scheduled for unilateral TKA were included. INTERVENTION Iron isomaltoside or placebo were administered intravenously over 30 min during surgical wound closure. MAIN OUTCOME MEASURES The primary outcome measure was the incidence of anaemia at 30 days after TKA: anaemia was defined as haemoglobin less than 12 g dl−1 for female and less than 13 g dl−1 for male. RESULTS In total, 89 patients were included in the final analysis (44 in the treatment group; 45 in the control group). The administered dose of iron isomaltoside in the treatment group was 1136 ± 225 mg. The incidence of anaemia at 30 days after TKA was significantly lower in the treatment group (34.1%, 15/44) than that in the control group (62.2%, 28/45): relative risk 0.55 (95% confidence interval, 0.34 to 0.88), P = 0.008. Haemoglobin concentration, serum ferritin concentrations, and transferrin saturation were also significantly higher in the treatment group at 30 days after TKA. CONCLUSION The intra-operative administration of iron isomaltoside effectively prevents postoperative anaemia in patients undergoing TKA, and thus it can be included in patient blood management protocols for reducing postoperative anaemia in these population. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03470649. Correspondence to Jin-Tae Kim, Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul 03080, South Korea Tel: +82 2 2072 3295; e-mail: jintae73@gmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2020 European Society of Anaesthesiology

The efficacy of high flow nasal oxygenation for maintaining maternal oxygenation during rapid sequence induction in pregnancy: A prospective randomised clinical trial BACKGROUND High-flow nasal oxygenation (HFNO) for pre-oxygenation in rapid sequence induction (RSI) has only been assessed in volunteer parturients without intubation. OBJECTIVES To evaluate the efficacy of HFNO in comparison with the conventional facemask for oxygenation during RSI for caesarean section under general anaesthesia. SETTING Operating room in a tertiary hospital. DESIGN Prospective randomised, controlled study. PARTICIPANTS Thirty-four healthy parturients undergoing general anaesthesia for caesarean section. INTERVENTIONS Parturients were randomly assigned to HFNO or standard facemask (SFM) group. MAIN OUTCOME MEASURES The primary outcome measure was the PaO2 immediately after intubation. Secondary outcomes included lowest saturation throughout the intubation procedure, end-tidal oxygen concentration (EtO2) on commencing ventilation, blood gas analysis (pH, PaCO2), fetal outcomes and intubation-related adverse events. RESULTS PaO2 in the HFNO group was significantly higher than that in SFM group (441.41 ± 46.73 mmHg versus 328.71 ± 72.80 mmHg, P < 0.0001). The EtO2 concentration in the HFNO group was higher than that in the SFM group (86.71 ± 4.12% versus 76.94 ± 7.74%, P < 0.0001). Compared to baseline, PaCO2 immediately after intubation also increased significantly in both groups (HFNO group: 30.87 ± 2.50 mmHg versus 38.28 ± 3.18 mmHg; SFM group: 29.82 ± 2.57 mmHg versus 38.05 ± 5.76 mmHg, P < 0.0001), but there was no difference in PaCO2 between the two groups. There was no difference in lowest saturation, intubation times, duration of apnoea, pH value or fetal outcomes. CONCLUSIONS Compared with SFM, HFNO provided a higher PaO2 and EtO2 immediately after intubation in parturients. HFNO is safe as a method of oxygenation during RSI in parturients undergoing general anaesthesia for caesarean section. TRIAL REGISTRATION Clinical trial ChiCTR1900023121. Correspondence to Zhiqiang Liu, Department of Anaesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 Gaoke West Road, Shanghai 201204, P.R. China Tel: +021 20261023; e-mail: drliuzhiqiang@163.com © 2020 European Society of Anaesthesiology

Effects on BMI and regional prevalence of malignant hyperthermia pathogenic ryanodine receptor type 1 sequence variants in Switzerland: A retrospective cohort analysis BACKGROUND Ryanodine receptor type 1 (RYR1) sequence variants are pathogenic for malignant hyperthermia. Variant carriers have a subtle increase in resting myoplasmic calcium concentration compared with nonaffected individuals, but whether this has metabolic effects in daily life is unknown. OBJECTIVES We analysed the potential effect of malignant hyperthermia-pathogenic RYR1 sequence variants on BMI as a single factor. Due to the heterogeneity of genetic variants predisposing to malignant hyperthermia, and to incomplete information about their regional distribution, we describe the prevalence of RYR1 variants in our population. DESIGN A retrospective cohort study. SETTING A single University hospital. PATIENTS Patients from malignant hyperthermia families with pathogenic RYR1 sequence variants were selected if BMI was available. OUTCOME MEASURES BMI values were compared amongst malignant hyperthermia susceptible (MHS) and malignant hyperthermia-negative individuals using hierarchical multivariable analyses adjusted for age and sex and considering family clustering. Variant prevalence was calculated. RESULTS The study included 281 individuals from 42 unrelated malignant hyperthermia families, 109 of whom were MHS and carriers of the familial RYR1 sequence variants. Median [IQR] BMI in MHS individuals with pathogenic RYR1 variants was 22.5 kg m−2 [21.3 to 25.6 kg m−2]. In malignant hyperthermia-negative individuals without variants, median BMI was 23.4 kg m−2 [21.0 to 26.3 kg m−2]. Using multivariable regression adjusted for age and sex, the mean difference was −0.73 (95% CI −1.51 to 0.05). No carrier of a pathogenic RYR1 sequence variant was found to have BMI more than 30 kg m−2. Only 10 RYR1 variants from the list of the European MH Group were found in our cohort, the most common being p.Val2168Met (39% of families), p.Arg2336His (24%) and p.Arg614Cys (12%). CONCLUSION The observed tendency towards lower BMI values in carriers of malignant hyperthermia-pathogenic RYR1 sequence variants points to a possible protective effect on obesity. This study confirms regional differences of the prevalence of malignant hyperthermia-pathogenic RYR1 sequence variants, with just three variants covering 75% of Swiss MHS families. TRIAL REGISTRATION This manuscript is based on a retrospective analysis. Correspondence to Oliver Bandschapp, MD, Department of Anesthesia, Interdisciplinary Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital, University of Basel, Spitalstrasse 21, 4031 Basel, Switzerland Tel: +41 61 265 72 54; e-mail: oliver.bandschapp@usb.ch © 2020 European Society of Anaesthesiology

Effect of positive end-expiratory pressure during anaesthesia induction on nonhypoxic apnoea time in infants: A randomised controlled trial BACKGROUND Hypoxaemia occurs frequently in infants during anaesthetic induction. OBJECTIVE We evaluated the effect of positive end-expiratory pressure during anaesthesia induction on nonhypoxic apnoea time in infants. DESIGN Randomised controlled trial. SETTING Tertiary care children's hospital, single centre, from November 2018 to October 2019. PATIENTS We included patients under 1 year of age receiving general anaesthesia. INTERVENTION We assigned infants to a 7 cmH2O or 0 cmH2O positive end-expiratory pressure group. Anaesthesia was induced with 0.02 mg kg−1 atropine, 5 mg kg−1 thiopental sodium and 3 to 5% sevoflurane, and neuromuscular blockade with 0.6 mg kg−1 rocuronium. Thereafter, 100% oxygen was provided via face mask with volume-controlled ventilation of 6 ml kg−1 tidal volume, and either 7 cmH2O or no positive end-expiratory pressure. After 3 min of ventilation, the infants' trachea was intubated but disconnected from the breathing circuit, and ventilation resumed when pulse oximetry reached 95%. MAIN OUTCOME MEASURE The primary outcome was nonhypoxic apnoea time defined as the time from cessation of ventilation to a pulse oximeter reading of 95%, whereas the secondary outcome was the incidence of significant atelectasis (consolidation score ≥2) assessed by lung ultrasound. RESULTS Sixty patients were included in the final analysis. Apnoea time in the 7 cmH2O positive end-expiratory pressure group (105.2 s) increased compared with that in the control group (92.1 s) (P = 0.011, mean difference 13.0 s, 95% CI, 3.1 to 22.9 s). Significant atelectasis was observed in all patients without positive end-expiratory pressure and 66.7% of those with 7 cmH2O positive end-expiratory pressure (P = 0.019, 95% CI, 1.7 to 563.1, odds ratio 31.2). CONCLUSION Positive end-expiratory pressure during anaesthesia induction with face mask ventilation increased nonhypoxic apnoea time in infants. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov, NCT03540940. Correspondence to Hee-Soo Kim, MD, PhD, Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea Tel: + 82 2 2072 3659; fax: +82 2 747 8412; e-mail: dami0605@snu.ac.kr © 2020 European Society of Anaesthesiology

Supraglottic jet oxygenation and ventilation reduces desaturation during bronchoscopy under moderate to deep sedation with propofol and remifentanil: A randomised controlled clinical trial BACKGROUND Hypoxaemia is frequently seen during flexible bronchoscopies that are done with a nasal approach under the traditional sedation with propofol. This study investigated the potential benefits of supraglottic jet oxygenation and ventilation (SJOV) using the Wei nasal jet tube (WNJ) in reducing hypoxaemia in patients undergoing bronchoscopy under moderate to deep intravenous sedation using a propofol, lidocaine and remifentanil cocktail. OBJECTIVES Our primary objective was to evaluate the efficacy and complications of SJOV via the WNJ during flexible bronchoscopy under moderate to heavy sedation with propofol and remifentanil. DESIGN A randomised controlled clinical trial. SETTING The 180th Hospital of People's Liberation Army, Quanzhou, China, from 1 June to 1 November 2019. PATIENTS A total of 280 patients aged ≥18 years with American Society of Anesthesiologists' physical status 1 to 3 undergoing flexible bronchoscopy were studied. INTERVENTIONS Patients were assigned randomly into one of two groups, a nasal cannula oxygenation (NCO) group (n = 140) using a nasal cannula to deliver oxygen (4 l min−1) or the SJOV group (n = 140) using a WNJ connected to a manual jet ventilator to provide SJOV at a driving pressure of 103 kPa, respiratory rate 20 min−1, FIO2 1.0 and inspiratory:expiratory (I:E) ratio 1:2. MAIN OUTCOME MEASURES The primary outcome was an incidence of desaturation (defined as SpO2 < 90%) during the procedure. Other adverse events related to the sedation or SJOV were also recorded. RESULTS Compared with the NCO group, the incidence of desaturation in the SJOV group was lower (NCO 37.0% vs. SJOV 13.1%) (P < 0.001). Patients in the SJOV group had a higher incidence of a dry mouth at 1 min (13.1% vs. 1.5%, P < 0.001) than at 30 min (1.5% vs. 0%, P = 0.159) or at 24 h (0% vs. 0%). There was no significant difference between the groups in respect of sore throat, subcutaneous emphysema or nasal bleeding. CONCLUSIONS SJOV via a WNJ during flexible bronchoscopy under moderate to deep sedation with propofol and remifentanil significantly reduces the incidence of desaturation when compared with regular oxygen supplementation via a nasal cannula. Patients in the SJOV group had an increased incidence of transient dry mouth. TRIAL REGISTRATION Registered at www.chictr.org.cn (ChiCTR1900023514). Correspondence to Ping Xie, Department of Anesthesiology, 180th Hospital of PLA, Quanzhou 362000, China. E-mail: 21621853@qq.com This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2020 European Society of Anaesthesiology

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